HospitalInspections.org

Based on observation, interview, and document review, the facility failed to:

I. Provide individualized treatment based on the presenting needs of 3 of 12 active sample patients (B3, C8, and C14) and 1 active non-sample patient (C35) selected based on observations in the clinical areas. The facility relies on "Core Groups" for much of the treatment of patients, although the Core Groups are too large and generalized in nature to meet patients' individual needs. This failure results in patients remaining hospitalized without defined psychiatric treatment needs being addressed, with a possible resulting delay in discharge.

II. Ensure an adequate development of discharge options for 1 of 12 active sample patients (F12) with an extensive hospitalization of fifty-seven years, and 1 active non-sample patient (C35) selected based on observations in the clinical areas. Neither patient required active psychiatric treatment, and had not needed it for a significant period of time. Being hospitalized beyond the time needed to reach optimal benefits results in patients lack of opportunity for mental health and psychosocial improvement through transitional community services and community integration.

Findings include:


I. Failure to provide individualized treatment:

A. Description of treatment programming

1. "Core" groups, instituted in 2010, were a major treatment modality utilized at the facility. The groups were scheduled daily, Monday-Friday from 9:00 a.m.-11:00 a.m. and/or from 1:00 p.m.-3:00 p.m. Group leaders were from clinical disciplines including nursing, psychology, social work, therapeutic activities, and psychiatry. Group topics were different for each discipline and different across units. All patients on a unit were scheduled for "Core" groups if they were not assigned to another group or activity at that time. These groups were conducted in large rooms and observation revealed attendance often ranged to over 30 patients in a group.

2. Staff Interviews

a. During an interview with RN 1 (Registered Nurse 1) and RN 2 on 1/28/13 at 9:10 a.m., both nurses acknowledged Core groups were difficult to conduct with large numbers of patients in the groups.

b. During an interview with OT 1 (Occupational Therapist 1) on 1/29/13 at 10:05 a.m., OT 1 stated that Core groups were often conducted with large numbers of patients for a period of two hours and these groups were not effective. OT 1 stated that Core groups had previously included a time to divide patients into smaller groups and that process worked better.

c. During an interview with the Therapeutic Recreation Manager on 1/29/2012 at 4:30 p.m., he related that the administrative team had reviewed the Core Programming. The week following the survey, the hospital's plan was to reduce the number of patients in the Core Program.

d. During an interview with the Medical Director, Chief Medical Officer (CMO), and MD 5 (Medical Doctor 5), on 1/30/13 at 9:15 a.m., the CMO acknowledged that Core groups were not able to provide individualized treatment for all patients included in the groups. He stated that "we have to tweak this whole process [of Core group programming]."

B. Patient B3

1. Record Review

a. The Psychiatric Assessment (03/07/12) stated that Patient B3 was admitted due to "biting [herself/himself] and banging [her/his] head on the wall. [S/he] needed stitches for self sustained injuries. [S/he] had not improved after several weeks of acute hospitalization and was admitted to [the facility] for a longer term treatment and stabilization." At the time of the Psychiatric Assessment, the "Course in the Hospital" stated that Patient B3 "had periods where [s/he] became agitated and was assaultive." The mental status examination stated "mood is irritable. Affect... labile. [S/he] responds to internal stimuli and engages in self stimulatory behavior especially repetitive nodding of her head and movements with both hands...[s/he] has been seen to respond to hallucinations. [Her/his] impulse control is poor. [Her/his] attention is poor. Concentration is impaired. Immediate memory is poor."

b. A review of the "Individual Consumer Treatment Schedule" for Patient B3 indicated the following group therapies: "Core" groups 1:00 p.m. to 3:00 p.m. Monday through Friday; "Therapeutic Recreation Group Skills" 10:00 a.m. to 11:00 a.m. Monday and Tuesday; "Occupational Therapy Brain Power" 10:00 a.m. to 11:00 p.m. on Thursday. A review of the Therapeutic Recreation monthly note (1/2/13) stated "[S/he] refuses Core groups, tends to sleep and lacks interest in active participation." A review of the monthly Therapeutic Recreation note (1/29/13 at 9:45 a.m.) stated "[Her/His] participation in the afternoon Core program was minimal and usually limited to between 5-15 minute spans of time."

2. Observation

During observation of Patient B3 on 1/29/13 at 1:00 p.m. in "Core Group" with a total of 12 other patients present, Patient B3 was observed making little eye contact with the group leader or any of the other six staff present. Patient B3 slept for 15 minutes with no staff intervention.

3. Staff Interviews

a. During an interview with SW 4 (Social Worker 4) on 1/29/13 at 9:00 a.m., he stated that Patient B3 "has no group with the Social Worker because [s/he] is not ready for discharge group...in other groups [her/his] participation is minimal at best. [S/he] is not involved due to [her/his] responding to internal stimuli."

b. During an interview with OT 3 on 1/29/13 at 9:30 a.m., she stated, in reference to Patient B3, that "...It is so difficult to get Patent B3 to engage in anything while [s/he] is in the Core groups...the problem with [Patient B3's] involvement in the Core group is due to the number of patients in the group...I can't provide the attention [s/he] needs with 12 to 15 other patients in a group...[s/he] is only in the room (not participating)... My supervisor is on board that we the OT staff are not serving [her/him] to the best of our professional ability."

c. During an interview with MD4 on 1/29/13 at 10:15 a.m., he stated regarding Patient B3 that "Group participation is hard for this patient and it is a challenge for the staff to get [him/her] engaged when there is 20 other patients in the Core group... [s/he] has refused to go to the sensory room which is located in another building."

d. During an interview with Chief Social and Rehabilitative Services Executive on 1/30/13 at 8:45 a.m., he stated "We were running groups with two and three patients and it was not effective...The Core Program can provide programming for 20 patients at one time."


C. Patient C8

1. Record Review

a. The initial Psychiatric Assessment (12/19/12) stated Patient C8 was admitted on 12/19/12 due to "a long standing history of psychotic illness and treatment of acute psychosis." Mental status examination noted, "Mild poverty content of speech is noted. Mild to moderate loosening of associations is noted."

b. A review of the "Individual Consumer Treatment Schedule" for Patient C8 indicated the following group therapies: Core groups from 9:00-11:00 a.m. and from 1:00-3:00 p.m. Monday -Friday, "Med. Education" 5:30-6:00 p.m. Monday-Friday and "Smoking Cessation" 5:30-6:00 p.m. Saturday and Sunday.

c. A review of the progress notes, presented as evidence of active treatment, for the period between 12/19/12 and 1/2/13, indicated that Patient C8 was not able to attend groups. On 12/26/12 a note written by a TRSW (therapeutic recreation social worker) stated, "pt. (patient) has been having difficulty adjusting to ward routine and declining an invitation to attend the offered programs." A progress note on 1/1/13 read, "Patient has a short attn (attention) span, poor short term memory and at times looks as if [s/he] is lost." "[Patient C8] would not benefit from psycho-education at this time due to [his/her] poor attn span/memory."

2. Observation

On 1/29/13 patient C8 did not attend the scheduled 9:00 a.m. Core group nor was s/he provided with another therapeutic intervention.


3. Patient Interview

During an interview on 1/29/13 at 11:30 a.m., Patient C8 indicated [s/he] did not like the "Core" groups. When asked how staff members help the patient, Patient C8 replied, "They tell me what to do."

D. Patient C14

1. Record Review

a. Patient C14 was admitted on 11/30/06. The annual Psychiatric Assessment update was completed on 10/18/12. The "Course in Hospital" stated, "During course of the past year the patient has exhibited marked improvement in verbal and physical agitation as well as [his/her] ability to participate in unit activities."

b. A review of the patient's Master Treatment Plan (10/16/12) indicated the following problems: " Pt. displays poor frustration tolerance, impulsiveness and poor coping skills AEB (as evidenced by) numerous episodes of both verbal hostility and physical aggression, and Pt. displays impaired concentration/attention span and cognitive impairment AEB having difficulty attending to task, attempting to leave the program area and repeatedly asking the same questions."

c. A review of the psychology Core group attendance record for the period between 10/2/12 and 1/8/13, which was for attendance at 12 groups, listed the patient as having "minimal participation" for 9 of the 12 groups. The patient is listed as "disruptive " for 7 of the 12 groups and as "intrusive" during 5 of the 12 groups. A review of the OT/RT Core group attendance record for the period between 11/28/12 and 1/6/13 indicated for 12 groups, the patient had "minimal participation" for 10 of the 12 groups.

2. Observation

a. During an observation of a psychology Core group on 1/29/13 between 9:00 a.m. and 9:35 a.m., Patient C14 was observed to yell on two occasions, "When do we get snacks?" On the second occasion a staff member asked the patient to be quiet. The patient then shouted, "Can I watch TV now?" When patient C14 was told [s/he] could not watch television, Patient C14 shouted, "Alright then I won't take a (expletive) shower tomorrow." Patient C14 was not observed to participate in this group in any meaningful way.

3. Staff Interviews

a. During an interview with OT 2 on 1/28/13 at 2:15 p.m., OT 2 indicated that the large core groups were often disruptive and patients were unable to receive individual attention for their treatment needs.

b. During an interview on 1/29/13 at 1:40 p.m., MHT1 (Mental Health Technician 1) was asked about Patient C14's attendance at Core groups. MHT 1 indicated that many patients did not want to attend Core groups because they were too large, often with 25 patients.


E. Patient C35

1. Record Review

a. The annual Psychiatric Assessment (11/14/12) stated that Patient C35 was admitted 12/10/08 due to "psychiatric complications of Huntington's disease" including "difficult (sic) with memory, mood lability, significant impulsivity and psychosis." At the time of the annual assessment, the "Course in the Hospital" stated "it is difficult to assess the patient's cognition because of [his/her] inability to communicate consistently...behavioral disturbances...have improved significantly during the past year...[His/her] current medication regimen has resulted in rare but episodic efforts to be physically aggressive with staff without provocation. [His/her] impulsive aggression is noted when [s/he] has soiled [him/herself]." The "current mental status examination" stated "the patient typically lies in the Broda chair and/or is seen in bed when not ambulating...Affect appears neutral, labile (mildly labile), constricted and blunted. Thought process and content difficult to assess. [S/he] does not appear to be responding to internal stimuli. Records indicate a history of cognitive difficulties including memory and executive functioning. Insight is unable to be assessed at this time."

b. A review of the "Individual Consumer Treatment Schedule" for Patient C35 indicated the following group therapies: "Core" groups 9:00-11:00 a.m. Monday-Friday and 1:00-3:00 p.m. Friday afternoon, "Sensory Program" 2:30-3:00 p.m. Monday and Wednesday, "Cognitive Skills" 1:30-2:00 p.m. Tuesday and Thursday, "Med Ed (medication education)" 10:30-11:15 a.m. Saturday, "Fundamentals of Rec (recreation)" 5:30-6:30 p.m. Saturday, and "Music Relax (relaxation)" Sunday 10:30-11:30 a.m. A review of the progress notes presented as evidence of active treatment for the period between 11/10/12 and 1/2/13 indicated that the only active treatment documented, other than additional medication doses as needed, was as follows: Nursing (monthly note 12/2/12 at 8:30 p.m.) - "Attends on Ward programs [with] Medication Education given on Saturdays from 1030-1115. The need for medication is reviewed [with] [Patient C35] by Nursing Staff; questionable understanding of information presented is noted;" Occupational Therapy (monthly progress note 12/10/12 at 12:15 p.m.) - "During the past 30 days [Patient C35] participated in 5 out of 8 '1:1' OT programs;" Therapeutic Recreation (TR) (monthly progress note dated 12/14/12 at 12:05 p.m.) - "TR staff will include [Patient C35] in Fundamentals of Recreation Group Program...[Patient C35] has been either excuse (sic) or spectated (sic) in the Fundamental of Rec Program. Regarding the Therapeutic Recreation core program, [Patient C35] attended 4 of 5. [Patient C35] attended Trivia program were (sic) [s/he] verbally responded to a question." A review of the "Group Participation Record" for "Core" groups provided by psychology, therapeutic recreation, occupational therapy, and nursing staff between 10/2/12 and 1/8/13 indicated that Patient C35 attended 19 groups and did not attend 27 groups. The participation in groups by Patient C35 was rated as "minimal," "no participation," or "left early" in all but one group.

2. Observation and Interview
During an observation and attempted interview on 1/29/13 at 11:40 a.m., Patient C35 was observed in a positioning wheelchair being fed a pureed diet by nursing staff. Patient C35 was able to follow the surveyor with his/her eyes but made no verbal or other gestures to indicate s/he understood simple questions.

3. Staff Interviews

During an interview with RN 1 on 1/29/13 at 10:50 a.m., he stated that Patient C35 required "total [nursing] care." He stated that Patient C35 was transferred to the current ward because Patient C35 would receive "more hands on [nursing] care." He stated that Patient C35 was "non-ambulatory" and "most times needs 1:1 [staffing]." He stated that Patient C35 did not generally respond verbally in a coherent manner. He stated that "core" group programming appeared to overstimulate Patient C35 leading to outbursts by Patient C35. RN 1 stated that he believed Patient C35 received "nothing out of" large group programming.


II. Failure to ensure adequate development of discharge options

A. Patient F12

1. Review of Records

a. The annual Psychiatric Assessment (10/15/12) stated that Patient F12 was a 75 year old admitted 3/4/57. At the time of the annual assessment, Patient F12 was described as "presents no management problem, or any difficulty. [S/he] continues to be considered in partial remission having had no recurrence of any bizarre behavior, or any psychotic symptoms." The "Course in the Hospital" stated "there has been no change over the past one year and [s/he] continues on a small dose of Zyprexa [a psychotropic medication]. There has been no reoccurrence of psychotic symptoms in terms of hallucinations, or delusions nor have there been any bizarre behaviors...behavior is appropriate. There were no mood changes and no agitated behavior over the past one year." The annual assessment stated "at the present time [s/he] seems to be in almost complete remission. There are no hallucinations, or delusions."

b. The annual Psychosocial Assessment and Plan (10/5/12) stated that Patient F12 "is cooperative and pleasant and attends and participates in all assigned programs. [S/he] communicates well and makes [his/her] needs known and is independent in [his/her] ADL's (activities of daily living)...[S/he] is comfortable with the structure and routine of the hospital environment and is not interested in living elsewhere. Due to [his/her] dependence on a structured environment, recommended plans for community living would include placement in a supervised setting such as a PCBH (personal care boarding home)."

c. The Master Treatment Plan (10/9/12, reviewed 1/28/13) stated the "discharge criteria" as Patient F12 "must agree to discuss discharge planning and to tour possible placements." The "anticipated type of post-discharge placement" stated at the time of admission was "Personal Care Boarding Home." The only problem listed was that Patient F12 "refuses to participate in any discharge planning as evidenced by [his/her] refusal to discuss discharge at Treatment Team." The only long term goal was stated as Patient F12 "will agree to participate in discharge planning," and the only short term goal was "will agree that the outside world is not an unsafe place." The only intervention for social services was the social worker "will meet with [Patient F12] a minimum of 1/month to encourage [him/her] to participate in an off grounds outing to visit a potential placement site in the [local] area." No other social work interventions were included to facilitate the discharge of Patient F12.

d. Social work progress notes on 2/27/12, 5/18/12, 6/15/12, 7/16/12, and 9/10/12 all stated that Patient F12 "has demonstrated no further progress toward [his/her] goal of being less fearful of living in a community setting." Social work progress notes on 10/9/12, 11/5/12, 12/4/12, and 1/3/13 all stated that Patient F12 "has made no further progress toward [his/her] goal of going off-grounds w/SW (with social worker) to explore possible placements. [Patient F12] displays no interest in living outside of the hospital environment."

2. Patient Interview

During an interview with Patient F12 on 1/29/13 at 9:45 a.m., s/he stated "I want to stay here. I don't want to get out...I like this place better. I don't have to pay for a car. I don't have to pay for a house. I don't have to pay for an electric bill. I don't have to pay a gas bill..." S/he stated that staff had been "harassing" him/her [to be discharged] "since 1988." When asked how s/he was being "harassed" about being discharged, s/he stated "they just ask me at treatment team and I tell them 'no' and that's the end of it. I go on trips to the outside world but that's fine. I know I'm coming back here." S/he stated that s/he attended all groups and met expectations of the unit because "if you don't keep the rules, they will force you out." When asked about attending groups, Patient F12 stated, "For me, it's something to do. If I didn't go on trips, I'd be sitting on the ward."

3. Staff Interviews

a. During an interview on 1/30/13 at 10:00 a.m., SW 5 stated that her intervention for Patient F12 was to meet with him/her once monthly and "talk about placements in the community." SW 5 stated that she had not sent any information to community providers for placement Patient F12 because Patient F12 would not agree. She stated that no new interventions were attempted in the previous year. She agreed that a community "personal care boarding home" would be the level of care needed for Patient F1.

b. During an interview with Psychologist 1 on 1/29/13 at 9:40 a.m., she stated that Patient F12 was "functioning pretty well...[s/he] does everything [s/he] is supposed to do here." Psychologist 1 stated that she had been working with Patient F12 toward discharge for two or three years without success.

c. During an interview with MD 1, Patient F12's attending psychiatrist, on 1/29/13 at 10:00 a.m., he stated that Patient F12's mental status had been stable "for a long time." He stated no psychotropic medication changes had been made for over a year. The last medication change consisted of a decrease in the dosage of olanzapine (a psychotropic medication).

d. During an interview with the Director of Social Work on 1/29/13 at 3:15 p.m., when asked about the appropriateness of Patient F12's continued hospitalization at the facility, he stated that Patient F12's "being here is not acceptable."

e. During an interview with the Medical Director, Chief Medical Officer (CMO), and MD 5, on 1/30/13 at 9:15 a.m., the CMO stated that Patient F12 was "a difficult case" and "not a lot of activity" had occurred to address the discharge of Patient F12.

B. Patient C35

1. Record Review

a. The annual Psychiatric Assessment (11/14/12) stated that Patient C35 was admitted 12/10/08 due to "psychiatric complications of Huntington's disease" including "difficult (sic) with memory, mood lability, significant impulsivity and psychosis." At the time of the annual assessment, the "Course in the Hospital" stated "it is difficult to assess the patient's cognition because of [his/her] inability to communicate consistently...behavioral disturbances...have improved significantly during the past year...[His/her] current medication regimen has resulted in rare but episodic efforts to be physically aggressive with staff without provocation. [His/her] impulsive aggression is noted when [s/he] has soiled [him/herself]." The "Current Mental Status Examination" stated "the patient typically lies in the Broda chair and/or is seen in bed when not ambulating...Affect appears neutral, labile (mildly labile), constricted and blunted. Thought process and content difficult to assess. [S/he] does not appear to be responding to internal stimuli. Records indicate a history of cognitive difficulties including memory and executive functioning. Insight is unable to be assessed at this time."

c. The Annual Comprehensive Assessment completed by nursing staff (11/10/12) stated that Patient C35 required "total care" for dressing, grooming, eating, hygiene, and toileting. The assessment stated "pt (patient) is non-verbal most of time. When [s/he] does speak [s/he] will shout out sentences..."

d. The Annual Comprehensive Assessment completed by occupational therapy staff (11/2/12) stated that an assessment of Patient C35's "adaptive skills" was not possible and Patient C35 was "dependent on staff with ADL's (activities of daily living)" and "needs 24/7 supervision."

e. The annual History and Physical Examination (11/7/12) for Patient C35 stated "[his/her] dementia is rapidly progressing." The examination stated Patient C35 "is currently confined to a Broda chair due to severe gait instability...[S/he] is on a pureed diet and is an extreme risk for choking with [his/her] progressive Huntington's Disease...The patient is normally not ambulatory...[S/he] is non-verbal at this time except for occasional screams and yells."

f. The Annual Comprehensive Assessment for Patient C35 completed by social work staff (11/7/12) stated that "though pt (patient) initially was working towards improved coping for depression and anxiety, [his/her] present condition warrants the need to deal with [his/her] debilitating and likely terminal illness with the assistance of supportive clinical staff, so [his/her] quality of life is maintained at the highest level. [S/he] also requires 24/7 total care for all [his/her] activities of daily living." The assessment stated the "discharge plan" was "Pt will require a 24 hr (hour) a day supervised setting with nursing and medical staffing."

g. The Master Treatment Plan (11/7/12, revised 1/4/13) did not indicate a problem related to the discharge placement of the patient. The "anticipated type of post-discharge placement," as stated at the time of admission, was "nursing home." The only social work intervention was that the social worker "will meet with [Patient C35] once a month for 15 minutes to develop an understanding and comfort level with the discharge process."

2. Patient Interview/Observation

During an observation and attempted interview on 1/29/13 at 11:40 a.m., Patient C35 was observed in a positioning wheelchair being fed a pureed diet by nursing staff. Patient C35 was able to follow the surveyor with his/her eyes but made no verbal or other gestures to indicate s/he understood simple questions.

3. Staff Interviews

a. During an interview with SW 2 on 1/29/13 at 11:10 a.m., she stated that no referral for placement outside the hospital had been made for Patient C35 during the previous year. SW 2 stated that she would not make a referral for placement until Patient C35's attending psychiatrist told her to begin the process. She stated "I take all direction from the psychiatrist and the treatment team" about when to begin the process of discharge placement.

b. During an interview with MD 2 on 1/29/13 at 11:00 a.m., she stated that Patient C35's behavior was "stable during the last six months." She stated that Patient C35 demonstrated no significant aggressive behaviors for the previous three to four months. MD 2 stated that she was "waiting for a consolidation of [Patient C35's] gains" before Patient C35 would be ready for discharge. MD 2 stated that she felt an additional three months of hospitalization would be required before this "consolidation" occurred.

c. During an interview with MD 3, medical physician for Patient C35, on 1/29/13 at 11:15 a.m., he stated that Patient C35 had a rapidly progressing course of neurological decline from Huntington's dementia. He stated that Patient C35 was nonverbal, required assistance for personal care, could not ambulate without assistance, and had dysphagia. He estimated Patient's C35's life expectancy was approximately only one to two years.

d. During an interview with RN 1 on 1/29/13 at 10:50 a.m., he stated that Patient C35 required "total [nursing] care." He stated that Patient C35 was transferred to the current ward because Patient C35 would receive "more hands-on [nursing] care." He stated that Patient C35 was "non-ambulatory" and "most times needs 1:1 [staffing]."

e. During an interview with Psychologist 2 on 1/29/13 at 11:20 a.m., he stated that the cognitive level of Patient C35 was "at the primitive stage of functioning."

f. During an interview with the Director of Social Work on 1/29/13 at 3:15 p.m., he stated that applications for nursing home placement for Patient C35 would not occur until the attending psychiatrist for the patient stated that the patient was ready for discharge. He stated that nursing home placement for patients was an "extended process" requiring involvement and approval from State-level agencies. He stated that waiting until the attending psychiatrist indicated the patient was ready for discharge "delays the discharge" of patients like Patient C35.

g. During an interview with the Medical Director, Chief Medical Officer (CMO), and MD 5, on 1/30/13 at 9:15 a.m., the CMO agreed that some discharge planning should have been occurring for Patient C35. He stated that attempts at placement "should be ongoing" but was unaware of any recent attempts at locating an appropriate placement for Patient C35.

Based on record review and interview, the facility failed to provide social work progress notes that included information about patients' progress or lack of progress toward treatment goals for 1 of 12 active sample patients (F12). This failure potentially impedes the treatment team's ability to assess each patient's response to treatment provided by social work staff.

Findings include:

A. Record Review

Patient F12 was admitted on 3/4/55. The Social work progress notes for Patient F12 on 5/18/12, 6/15/12, and 7/16/12 were identical, the notes on 9/10/12 and 10/9/12 were identical, and the notes on 11/5/12, 12/4/12, and 1/3/13 were identical. No monthly progress note was available for the month of 4/12. These notes did not describe any changes in the Patient F12's status or discharge planning.

B. Staff Interviews

1. During an interview on 1/30/13 at 10:00 a.m., SW 5 (Social Worker 5) stated that some of her progress notes for Patient F12 were identical because "a lot of the stuff is the same, it's hard to come up with new things" [to write in progress notes].

2. During an interview with the Director of Social Work on 1/29/13 at 3:15 p.m., he stated that identical notes were not adequate and should reflect changes in the patient, document family contacts and changes in discharge planning.

Based on observation, interview and record review, the Medical Director failed to:

I. Ensure individualized treatment based on the presenting needs of 3 of 12 active sample patients (B3, C8, and C14) and 1 active non-sample patient (C35) selected based on observations in the clinical areas. The facility relies on "Core Groups" for much of the treatment of patients, although the Core Groups are too large and generalized in nature to meet patients' individual needs. This failure results in patients remaining hospitalized without defined psychiatric treatment needs being addressed, with a possible resulting delay in discharge. (Refer to B125-I).

II. Ensure an adequate development of discharge options for 1 of 12 sample patients (F12) with an extensive hospitalization of fifty-seven years and 1 active non-sample patient (C35) selected based on observations in the clinical areas. Neither patient required active psychiatric treatment, and had not needed it for a significant period of time. Being hospitalized beyond the time needed to reach optimal benefits results in patients' lack of opportunity for mental health and psychosocial improvement through transitional community services and community integration. (Refer to B125-II.)

Based on record review and interviews, the Director of Social Services failed to ensure social service progress notes in the medical records were current record of the patients' progress for 1 of 12 active sample patients (F12). Instead, the progress notes were identical notes for three months. This results in the treatment team not obtaining information pertinent functioning of the patient in the hospital setting as well as readiness for discharge.

Findings include:

A. Policy Review

Position Description for Social Worker Manager (Director of Social Work) dated 2/8/2012 states under Section: Supervisory: "The Social Worker Manager: (2) is responsible for the provision of social work services to patients and their families and monitors the quality of these services."

B. Record Review

Patient F12 was admitted on 3/4/55. The Social work progress notes for Patient F12 on 5/18/12, 6/15/12, and 7/16/12 were identical, the notes on 9/10/12 and 10/9/12 were identical, and the notes on 11/5/12, 12/4/12, and 1/3/13 were identical. No monthly progress note was available for the month of 4/12. These notes did not describe any changes in the Patient F12's status or discharge planning.

C. Interview

During an interview with the Director of Social Work on 1/29/13 at 3:15 p.m., he agreed that the monthly notes were identical and stated "I want the social worker to document how the clients are doing clinically from the last month."

Based on interview and document review, the Social Work Director failed to assure effective discharge planning for patients. This resulted in 2 of 12 active sample patients who no longer required acute hospital care, not being discharged in a timely way. These two patients (C35 and F12) lacked psychiatric symptoms with documented need for acute inpatient psychiatric treatment. These patients were retained because of circumstances unrelated to their psychiatric needs. Failure to manage the discharge planning of patients who are not in need of inpatient psychiatric treatment results in failure to treat patients in the least restrictive setting appropriate to their needs.

Findings include:

I. Failure to ensure adequate development of discharge options (Refer to B125-II).

Findings include

A. Document Review

1. The Department of Social Service Policy Re: Discharge Planning- Policy Statement Revised Date: January 27, 2011 states "When a patient has been recommended and referred for discharge by the treatment team, the Social Services Worker will contact and/or involve the relatives, the Community MH/MR (Mental Health/Mental Retardation) in the planning and this is to occur within two (2) working days following the treatment team's recommendation." The policy also states under Responsibility: "It is the responsibility of each worker's supervisor to see that these procedures are carried out. All Social Service Workers are responsible for the implementation of this procedure."

2. Position Description for Social Worker 1 dated 1/13/12 states under Section: Discharge Planning: "Discharge planning is of importance and begins as soon as the case is assigned. This includes working with the patient in planning for... aftercare... Considerable attention is given to aftercare planning in order to provide a smooth transition to the community."

3. Position Description for Social Worker Manager (Director of Social Work) dated 2/8/2012 states under Section: Supervisory: "The Social Worker Manager: (2) is responsible for the provision of social work services to patients and their families and monitors the quality of these services."

B. Interviews

1. In an interview on 1/29/13 at 3:15 p.m. the Social Work Director stated "Our license is for long term care and some patients would like to stay forever....and the doctor is the one that says that we (social workers) can began the discharge (planning)."

2. In interview on 1/30/2013 at 9:50 a.m. SW 4 (Social Worker 4) stated "It is always a treatment team decision but the doctor (psychiatrist) is the captain of the ship and he tells me when to start the discharge." SW 4 also added "It is my understanding that Harrisburg (MH/MR Services office) requires that a patient must have a Community Support Plan meeting before discharge...and the psychiatrist is the only team member that can place a patient on that list for Community Support Plan meeting; no one is discharged according to Harrisburg without a Community Support Team meeting."